老年人髋部骨折的骨密度及影响因素的分析

目的调查分析成都地区老年人髋部骨折骨密度变化和影响因素,为预防髋部骨折提供科学依据.方法骨折组答卷式调查有关指标,髋部作X线正斜侧位摄片,骨折组与非骨折组进行配对,均用DEXA测量L2～4,股骨上段骨密度(BMD),骨矿含量(BMC),骨面积(Area)等,并进行统计分析.结果股骨上段及L2～4的BMD、BMC骨折组明显低于非骨折组(P＜0.05),两组各进行男女性比较,女性均明显低于男性(P＜0.05),骨折组L2～4BMD男、女分别为0.872±0.178g/cm2,0.607±0.155g/cm2;非骨折组男女分男为0.921±0.147g/cm2,0.741±0.152g/cm2.同性别的骨面积Area两组比较无差异,骨折组骨质疏松症发生率76%明显高于非骨折组63%(P＜0.05);滑倒和被人撞倒股骨颈骨折发生率较高,自行拌倒者粗隆间骨折发生率较高.结论预防治疗骨质疏松症和避免摔倒,以防骨折的发生.     

全髋关节置换术后异位骨化及其预防

目的：探讨全髋关节置换术后异位骨化发生的原因、机制及其预防方法。方法：将139例接受全髋关节置换的患者入院时随机分为3组,A组53例,B组49例,C组37例,分别于术后次日口服维生素C（100mg,3/d)、消炎痛（25mg/3/d)和布洛芬（200mg,3/d),连续应用4周。术后3个月复查时行X线片检查。结果：异位骨化情况按Brooker分类,A组：0级24例,I级6例,Ⅱ级13例,Ⅲ级7例,Ⅳ级3例,异位骨化发生率54．7％（29／53）。B组：0级42例,Ⅰ级5例,Ⅱ级2例,发生率14．3％（7／49）。C组：0级32例,Ⅰ级3例,Ⅱ级、Ⅲ级各1例,发生率13．5％（5／37）。经统计学分析,异位骨化发生率A组与B组、A组与C组之间有显著差别（P＜0．01）,B组与C组之间无显著差别（P＞0．05）。结论：全髋关节置换术后发生异位骨化的原因很多,发生机制尚不清楚,非甾体类消炎镇痛类药物可有效地预防其发生。     

Hip preserving procedures for osteonecrosis of the femoral head after collapse

Osteonecrosis of the femoral head (ONFH) affects mainly young patients and causes secondary hip osteoarthritis if remains untreated. Several operative treatments have been introduced with successful outcomes in the early stages. However, in late stages of ONFH treatment may be challenging due to the progressive nature of disease and many surgeons prefer arthroplasty option after collapse. Considering the size, age and etiology an effort should be made to preserve hip joint selected patients with early collapse or minimal arthritic changes. The purpose of the current review is to discuss the results of joint preserving procedures for late stages of ONFH.     

TI VIBE inversion MRI – An alternative to CT for imaging of hip pain

IntroductionMR and CT are excellent complimentary diagnostic modalities for evaluation of hip pain which are often used together along with radiographs. However, CT involves radiation, which is a concern particularly in younger patients. T1VIBE is a 3D gradient echo MR sequence with high intrinsic contrast between the bone and soft tissues with multiplanar capabilities.AimWe performed a study to assess if TIVIBE can be used to complement MR for evaluation of hip pain in young adults and to see if measurements and angles can be calculated using T1VIBE inversion images with similar accuracy to CT scan.Material and methodsA retrospective review of 50 patients aged less than 40 years, who had MR (including TIVIBE) and CT of pelvis was performed. Post surgical patients were excluded. Some important measurements such as Centre edge angle, Tonnis’ angle, anterior acetabular sector angle, posterior acetabular sector angle and acetabular version were independently measured by two readers on T1 VIBE inversion and CT images separately and measurements were compared. One reader performed the measurements again to assess for intra-observer error.ResultsThere was a female predominance (37 F, 13M) with an average age of 27.6 years (range of 17–39). There was no significant difference in the measurements between CT and TI VIBE inversion and there was good intra and interobservor reliability.ConclusionTI VIBE inversion sequence can be used as an alternative to CT with added advantage of alleviating the radiation exposure.     

北京地区老年髋部脆性骨折患者术后抗骨质疏松症药物治疗现状及影响因素分析

目的 评估北京地区老年髋部脆性骨折患者术后抗骨质疏松症药物（AOM）治疗现状并探讨其影响因素。方法 横断面研究。纳入2018年11月—2019年11月北京积水潭医院、北京医院、北京安贞医院、北京市昌平区医院、北京市顺义区医院、北京市房山区良乡医院收治的髋部脆性骨折患者1 963例,总结其人口学特征,并收集患者入院后30、120、365 d的临床资料,AOM治疗及健康基本补充剂使用情况。通过单因素和多因素logistic回归分析AOM治疗的影响因素。结果 1 963例老年髋部脆性骨折患者,住院时年龄65~102（79.3±7.2）岁,≥80岁患者占56.7%（1 113/1 963）;男性患者占30.8%（604/1 963）,女性患者占69.2%（1 359/1 963）;股骨颈骨折846例,股骨粗隆间骨折1 077例,股骨粗隆下骨折40例。综合3个时间点,在髋部骨折后1年内,33.0%（648/1 963）的患者接受过AOM治疗,71.0%（1 394/1 963）的患者使用过健康基本补充剂。入院后30、120、365 d患者AOM治疗率分别为23.0%（451/1 963）、17.9%（353/1 963）、21.0%（412/1 963）,健康基本补充剂使用率分别为59.0%（1 158/1 963）、45.0%（883/1 963）、38.0%（746/1 963）。单因素分析结果显示,年龄≥80岁[粗比值比（OR）=0.645,95%可信区间（CI） 0.495~0.840]、男性（粗OR=0.760,95% CI 0.581~0.996）、共管模式（粗OR=3.025,95% CI 0.973~9.405）、居住地农村（粗OR=0.523,95% CI 0.388~0.704）、AOM服用史（粗OR=7.612,95% CI 2.227~26.020）、既往骨质疏松症史（粗OR=5.065,95% CI 3.149~8.147）、骨质疏松评估（粗OR=1.379,95% CI 1.105~2.451）是AOM治疗的影响因素。多因素分析结果显示,年龄≥80岁（调整后OR=0.618,95% CI 0.488~0.781）、男性（调整后OR=0.716,95% CI 0.565~0.908）、居住地农村（调整后OR=0.492,95% CI 0.375~0.645）是AOM治疗的危险因素;共管模式（调整后OR=2.632,95% CI 1.004~6.897）、AOM服用史（调整后OR=4.870,95% CI 2.080~11.402）、既往骨质疏松症史（调整后OR=4.804,95% CI 3.253~7.096）、骨质疏松评估（调整后OR=1.393,95% CI 1.041~1.862）是AOM治疗的保护因素。结论 北京地区老年髋部脆性骨折患者的AOM治疗率偏低。年龄≥80岁、男性、在农村居住的髋部脆性骨折患者治疗率较低,可采取共管模式,术前进行骨质疏松诊断与评估,提高骨质疏松治疗率。     

Inside-out和Outside-in髋关节镜技术治疗股骨髋臼撞击征的疗效对比研究

目的：对比分析两种髋关节镜技术治疗股骨髋臼撞击征（femoroacetabular impingement,FAI）的临床疗效和并发症。方法：回顾性分析2016年6月至2019年6月采用髋关节镜手术治疗并获得随访的48例FAI患者。根据手术方式的不同分为两组,Inside-out组,由中央到外周;Outside-in组,由外周到中央。Inside-out组24例,男14例,女10例,年龄（39.8±7.6）岁;Outside-in组24例,男13例,女11例,年龄（39.5±9.1）岁。两组患者年龄、性别、体质量指数、侧别、撞击类型、病程、随访时间比较差异无统计学意义。对两组术后髋关节改良Harris （modified Harris hip score,mHHS）,非骨关节炎髋关节（nonarthritic hip score,NAHS）评分和术后并发症发生率进行比较。结果：两组患者术后髋关节功能评分mHHS和NAHS评分均较术前提高,但组间比较差异无统计学意义（P>0.05）。Inside-out组术后4例出现神经牵拉伤,3例医源性损伤;而Outside-in组仅1例神经牵拉伤。Inside-out组并发症发生率高于Outside-in组（16.7% vs 4.2%,χ²=5.400,P=0.020）。结论：Inside-out和Outside-in两种髋关节镜技术治疗FAI均可取得良好的临床效果,但相对于Inside-out技术,Outside-in技术术后并发症发生率低,针对符合适应证的患者可以优先选择。     

聚焦式体外冲击波联合离心锻炼治疗大转子疼痛综合征

目的：探讨聚焦式体外冲击波联合离心锻炼治疗股骨大转子疼痛综合征的临床疗效。方法：2017年9月至2019年6月,将符合研究标准的53例股骨大转子疼痛综合征（greater trochanteric pain syndrome,GTPS）的患者分为观察组（29例）和对照组（24例）。观察组,男8例,女21例,年龄38~62（49.96±6.39）岁,病程6~13（8.58±1.99）个月,采用聚焦式体外冲击波联合离心锻炼治疗;对照组,男5例,女19例,年龄39~62（52.79±5.86）岁,病程6~14（9.04±2.51）个月,单纯采用离心锻炼治疗。分别使用疼痛视觉模拟评分（visual analogue scale,VAS）和髋关节Harris评分评估两组患者治疗前及治疗后1、2、6个月时髋部疼痛缓解程度及髋关节功能恢复情况,比较治疗效果。结果：治疗后1个月,两组VAS、髋关节Harris评分及治疗成功率比较差异无统计学意义（P>0.05）;2个月时,观察组VAS （3.20±0.81）分低于对照组的（3.87±0.61）分（P<0.05）,髋关节Harris评分（81.93±2.43）分与对照组（82.12±2.34）分比较差异无统计学意义（P=0.770）,治疗成功率（58.62%,17/29）高于对照组（29.16%,7/24）（P=0.032）;6个月时,观察组VAS （2.24±0.68）分低于对照组的（3.12±0.53）分（P<0.001）,髋关节Harris评分（85.10±1.75）分高于对照组的（83.66±1.78）分（P=0.005）,治疗成功率（82.75%,24/29）与对照组（62.50%,15/24）比较差异无统计学意义（P=0.096）。结论：聚焦式体外冲击波联合离心锻炼能够显著缓解大转子疼痛综合征患者髋部疼痛症状,改善髋关节功能,安全性可靠,值得在临床实践中应用推广。     

Direct Anterior Approach in Lateral Decubitus Position Versus Supine Position for Unilateral Total Hip Arthroplasty: A Comparative Study

ObjectiveTo compare the clinical efficacy of the direct anterior approach in lateral decubitus position (L‐DAA) and supine position (S‐DAA) for unilateral total hip arthroplasty.MethodsA retrospective study was conducted on 89 patients who underwent primary unilateral total hip arthroplasty in our department between August 2016 and December 2017. There were 46 patients who underwent L‐DAA and 43 patients who underwent S‐DAA. The body mass index (BMI), operation time, blood loss, preoperative Hb, first day and third day postoperative Hb, incision length, hospital stay, preoperative and postoperative Harris score, preoperative and postoperative visual analogue scale (VAS) score, radiological evaluation, intraoperative and postoperative complication, postoperative absolute length difference of lower extremity were recorded and analyzed. P < 0.05 was set as the significant difference.ResultsAll patients were followed up for 8–23 months, with an average of 15.6 months. No significant differences were found in preoperative and postoperative Harris scores, preoperative Hb, incision lengths, radiological evaluations, preoperative and postoperative VAS scores, and hospital stay (P > 0.05). However, significant differences were detected in BMI, blood loss, first day and third day postoperative Hb, and operation time (P < 0.05). There were no postoperative complications in the L‐DAA and S‐DAA groups. During the operation, two cases of proximal femoral fracture occurred in the L‐DAA group, four in the S‐DAA group, and the difference was statistically significant. There were significant differences found in the postoperative absolute length difference of lower extremity between the two groups.ConclusionCompared with the S‐DAA approach, the L‐DAA approach had the advantages of shorter operation time and less blood loss. Compared with S‐DAA, it was easier to expose the proximal femur, and lower BMI was required in L‐DAA. However, it was more difficult to compare the length of both lower extremities in the L‐DAA approach than in the S‐DAA approach.     

Two‐Stage Revision Hip Arthroplasty with or without the Use of an Interim Spacer for Managing Late Prosthetic Infection: A Systematic Review of the Literature

The aim of the present paper was to identify, appraise, and synthesize the available evidence on two‐stage revision hip arthroplasty with or without the use of an interim spacer for managing late prosthetic infection. The review methodology was designed by referencing the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) checklist and flow diagram, and a Population, Intervention, Comparator, Outcomes and Study (PICOS) design framework was used to search for studies to incorporate within the review. Two independent investigators were involved in searching for relevant articles that fulfilled the inclusion criteria for the study. Critical appraisal of the selected articles was carried out using the relevant Critical Appraisal Skills Programme checklists. From an initial pool of 125 articles, four studies satisfied the inclusion criteria and quality assessment and were included for final review. Two patient groups were identified from within the selected studies: spacer and non‐spacer. Both groups were assessed in terms of functional outcome, infection cure rates, and technical difficulties encountered during treatment. Better functional outcome was reported in the spacer group, both in the interim period between the two stages and after completion of treatment. The use of spacers reduced operative difficulty during the second stage and accelerated patient discharge. Reinfection and infection persistence rates were higher in the non‐spacer group. Within the spacer group, articulated spacers performed better in all parameters. The results of this review reinforce the available evidence supporting the use of interim hip spacers in revision hip arthroplasty for managing prosthetic infection and also indicate that articulated hip spacers could be an attractive option going forward.     

Risk Factors and Outcomes for Preoperative Asymptomatic Pulmonary Embolism in Patients Aged 60 Years and Over with Hip Fracture

ObjectiveTo investigate the risk factors for, and outcomes of, preoperative asymptomatic pulmonary embolism (PE) in patients ≥60 years old following delayed operation for hip fracture.MethodsFrom March 2017 to December 2018, 90 patients aged ≥60 years with hip fracture who suffered a delay in surgery were recruited to this prospective study following admission to our hospital. Computed tomography pulmonary angiography (CTPA) was used to detect preoperative asymptomatic PE and calculated its incidence. Time from injury to admission, baseline characteristics, medical comorbidities, and blood biomarker levels were evaluated as potential risk factors. Logistic regression analysis was used to identify risk factors. Mortality and major bleeding events were recorded and compared between individuals with PE and without. Data were analyzed by t‐test, Mann–Whitney U test, χ ² test, Fisher''s exact test, and logistic regression analysis.ResultsThe incidence of preoperative asymptomatic PE was 18.9% (17/90 patients). In the univariate analysis, the risk factors for preoperative asymptomatic PE were male sex, hypertension, cerebrovascular accident, smoking, plasma D‐dimer level, potassium level, urea level, creatinine level, and cysteine level. Multivariate logistic regression analysis showed that the risk of preoperative asymptomatic PE was higher in patients with hypertension (odds ratio [OR] = 10.048; 95% confidence interval [CI], 1.118–90.333), cerebrovascular accident (OR = 20.135; 95% CI, 1.875–216.164), smoking (OR = 48.741; 95% CI, 4.155–571.788), high plasma D‐dimer levels (OR = 1.200; 95% CI, 1.062–157.300), and high plasma potassium levels (OR = 12.928; 95% CI, 1.062–157.300). All patients were followed up for 21.0 months (range, 2 to 36 months). Mortality within the first year postoperatively was higher in patients with PE (29.41% vs 9.59%, P = 0.046).ConclusionsIn view of the high incidence of preoperative asymptomatic PE and the inferior prognosis in individuals with PE, routine CTPA examination for preoperative asymptomatic PE could be useful for patients aged ≥60 years with hip fracture for whom surgery is delayed.